(1622) VA ECMO for Septic Cardiomyopathy due to Influenza A Infection & Streptococcal Toxic Shock Syndrome

Introduction: Streptococcal toxic shock syndrome (STSS) is a rare, life-threatening complication of invasive group A Streptococcal infection (GAS). We present a fatal case of influenza A infection, complicated by STSS and septic cardiomyopathy managed with veno-arterial extracorporeal membrane oxygenation (VA-ECMO).

Description: A 67-year-old female presented to the emergency department (ED) with worsening dyspnea, cough, and fever. She was prescribed antiviral after she tested positive for Influenza A but the therapy was not initiated. She was tachycardic and hypoxic with bilateral coarse rales and mottled extremities. She was found to have lactic acidosis with concomitant metabolic and respiratory acidosis. Her chest X-ray showed multifocal pneumonia. She was started on meropenem, vancomycin, and oseltamivir and needed mechanical ventilation. An echocardiogram showed global left ventricular hypokinesis with a left ventricular ejection fraction of 20-24%. A right heart catheterization showed elevated right heart filling pressures and findings consistent with cardiogenic shock. An intra-aortic balloon pump was placed, and the patient was transitioned onto VA-ECMO. She was anuric and acidotic needing renal replacement therapy. Arterial Doppler studies showed occlusion of the right distal anterior tibial artery and left distal radial artery. Blood and sputum cultures yielded Streptococcus pyogenes. She was started on intravenous immunoglobulin for TSS. However, she developed sluggish pupils and became unresponsive. A CT head revealed a right-sided subacute infarction. A CT angiogram showed extensive bilateral pulmonary edema and/or pneumonia and ischemic changes in the liver, spleen, small bowel, and colon. The patient was transitioned to comfort care and passed away after the withdrawal of life support.

Discussion: STSS may rarely involve myocardial depression, possibly linked to streptolysin O . We opted for VA-ECMO due to persistent hemodynamic instability and global hypokinesis despite IABP and dobutamine. This case underscores the importance of recognizing secondary bacterial infections in influenza, particularly GAS. Though VA-ECMO benefits septic shock, its efficacy In TSS-induced cardiomyopathy warrants further exploration.